Maternal Mortality—United States, 1982-1996 FREE

MMWR. 1998;47:705-707

1 figure omitted

MATERNAL and infant mortality are basic health indicators that reflect a nation's health status. In the United States, infant mortality has declined steadily; however, this is not true for maternal mortality. This report presents data from death certificates compiled by CDC's National Center for Health Statistics, which indicate that in the United States, the annual maternal mortality ratio* remained approximately 7.5 maternal deaths per 100,000 live births during 1982-1996.

Annual maternal mortality ratios were calculated using information contained on death certificates filed in state vital statistics offices and compiled by CDC.^{1 - 2} Maternal deaths were defined as those deaths that occurred during a pregnancy or within 42 days of the end of a pregnancy and for which the cause of death was listed as a complication of pregnancy, childbirth, or the puerperium (International Classification of Diseases, Ninth Revision, codes 630-676). Maternal mortality ratios were calculated as the number of maternal deaths per 100,000 live births.^{1 - 2} In 1930, the national maternal mortality ratio was 670 maternal deaths per 100,000 live births.³ The ratio declined substantially during the 1940s and 1950s, and continued to decline until 1982. During 1982-1996, the annual maternal mortality ratio fluctuated between approximately 7 and 8 maternal deaths per 100,000 live births. During that time, trends by race were similar to the overall ratio, and no reductions were observed for either black or white women. Maternal mortality ratios remained higher for black women than for white women. Ratios for black women generally fluctuated between 18 and 22 per 100,000 births and for white women between 5 and 6 per 100,000 live births.

Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Vital Statistics, National Center for Health Statistics, CDC.

Since 1982 in the United States, no progress has been made toward achieving the Healthy People 2000 goal of 3.3 maternal deaths per 100,000 live births set in 1987 (objective 14.3).⁴ The reason for this lack of improvement in maternal mortality is not clear. However, during this same time period, infant mortality has declined steadily because of advances in the survival of low birthweight and preterm infants and in the prevention of some causes of postneonatal mortality, such as sudden infant death syndrome.

The United States has not reached an irreducible minimum in maternal mortality; WHO estimates demonstrate that 20 countries have reduced maternal mortality levels to below those of the United States.⁵ Primary prevention of maternal deaths, such as those associated with ectopic pregnancy and some cases of infection and hemorrhage, is possible. However, some complications that can occur during pregnancy cannot be prevented (e.g., pregnancy-induced hypertension, placenta previa, retained placenta, and thromboembolism). Nevertheless, more than half of all maternal deaths can be prevented through early diagnosis and appropriate medical care of pregnancy complications.^{6 - 7} Hemorrhage, pregnancy-induced hypertension, infection, and ectopic pregnancy continue to account for most (59%) maternal deaths.

When compared with white women, black women continue to have four times the risk for dying from complications of pregnancy and childbirth,² although the risk for developing maternal complications is less than twice that of white women.⁸ This suggests that access to and use of health-care services for early diagnosis and effective treatment, if complications develop, may be a factor. In 1996, if the maternal mortality ratio for black women were equal to that for white women, the national maternal mortality ratio would have declined by 32% from 7.6 to 5.1 per 100,000 live births.

In this report, maternal mortality ratios are based solely on vital statistics data and are underestimates because of misclassification. The number of deaths attributed to pregnancy and its complications is estimated to be 1.3 to three times that reported in vital statistics records.⁶ Misclassification of maternal deaths occurs when the cause of death on the death certificate does not reflect the relation between a woman's pregnancy and her death. In addition, the inclusion of deaths causally related to pregnancy that occur between 43 and 365 days postpregnancy can increase the number of maternal deaths identified by 5%-10%.⁶

To identify interventions that may have an impact on reducing maternal mortality, approximately 25 states have reestablished maternal mortality review committees. These committees review various factors that may have contributed to maternal deaths, including the quality of medical care and systemic problems in the health-care delivery system. To assess the problem and develop appropriate interventions to reduce the number of maternal deaths, all states should implement active surveillance of maternal mortality, including maternal mortality review committees.

In 1998, the World Health Organization designated Safe Motherhood as the focus for World Health Day (April 7), indicating the importance of this issue globally. In the United States, several measures that need to be implemented include providing all women with access to family planning services, because unintended pregnancies are associated with higher risks for both mother and infant.⁹ Women should know how to prevent sexually transmitted diseases (STDs), and women with STDs need effective and early treatment to prevent ectopic pregnancies. All women need access to culturally appropriate and quality prenatal, delivery, and postpartum care. The prevention of complications and the early diagnosis and effective treatment of any complication is critical. Although prenatal-care use in the United States has been increasing, in 1996, approximately 10% of all pregnant women received inadequate or no prenatal care.¹⁰

In the United States, the theme for World Health Day 1998 was "Invest in the Future: Support Safe Motherhood." The proposed Healthy People 2010 goal for maternal mortality remains 3.3 maternal deaths per 100,000 live births. Unless investments are made in improving maternal health for all women, this goal will not be reached.

*CDC's National Center for Health Statistics uses the term maternal mortality rate. In this report, the term "ratio" is used instead of rate because the numerator includes some maternal deaths that were not related to live births and thus were not included in the denominator.

MMWR. 1998;47:715-717

THIS STATEMENT by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) presents and recommends a programmatic strategy—the use of a reminder and/or recall (R/R) system by vaccination providers—to increase vaccination rates. In 1992, a national survey indicated that 8% of pediatricians and 5% of family physicians had implemented a manual vaccination R/R system and 6% and 5%, respectively, used a computer-based system for vaccination R/R messages.¹ In 1993, the National Vaccine Advisory Committee issued the "Standards for Pediatric Immunization Practices," which recommend that all public and private health-care providers use a vaccination R/R system.² These standards were endorsed by ACIP, AAP, and AAFP. By 1995 a survey indicated that R/R systems were used by 35% of pediatricians and 23% of family physicians (R. Zimmerman, University of Pittsburgh School of Medicine, personal communication, 1995).

The reminder component consists of mail and/or telephone messages to remind parents or guardians of vaccination due dates for their children. Reminder messages can improve parents' awareness that vaccinations are due and the importance of keeping appointments, therefore increasing the up-to-date vaccination status of children. The recall component consists of mail and/or telephone messages to parents or guardians of children who are past due for one or more vaccinations. Recall messages can decrease vaccination drop-out rates and reduce the time children remain at risk for vaccine-preventable diseases. R/R systems can be operated manually (e.g., by monthly tickler file) or can be automated (e.g., by computer-generated mailings or telephone calls). Messages from automated systems can be modified to address special needs (e.g., language).

The implementation of vaccination R/R systems has potential benefits beyond improved vaccination coverage rates. Patients of all ages who are due or overdue for recommended vaccinations also may have fallen behind in health supervision visits and may experience barriers to health care in general. Vaccination R/R systems may help identify patients who are at risk for not receiving comprehensive primary care. R/R systems also can be established independently for improving attendance for child health supervision visits and other recommended preventive health service visits, including adult vaccination,³ cervical cancer screening,⁴ and lead screening. The cost-effectiveness of R/R systems for a provider can be dependent on the number of patients, the documented level of vaccination coverage, the provider's level of computerization, and the intensity with which the provider uses the R/R system.^5,6

Properly implemented, the R/R strategy contributes to high, sustainable vaccination coverage levels. Studies of the effectiveness of mail or telephone reminder messages generally have demonstrated improvements in patient compliance for a variety of scheduled health-care visits, including vaccinations.^7-9 Among patients scheduled for a vaccination visit who received a single autodialer-based reminder call the night before a scheduled visit, attendance was 57% compared with 20% in the control group who received no reminder⁶; 41% of patients who received a vaccination R/R message visited the provider within 30 days compared with 28% of those who did not receive a reminder.¹⁰

The ACIP, AAFP, and AAP recommend the regular use of R/R systems by public and private health-care providers in settings that have not achieved high documented levels of age-appropriate vaccinations. For reminder systems, messages should be delivered close to the due date for vaccinations. In recall systems, messages should be delivered promptly if the scheduled visit is missed. Implementation of these recommendations can contribute substantially to improving vaccination coverage at the provider level.

Advisory Committee on Immunization Practices, Atlanta, Georgia. American Academy of Family Physicians, Kansas City, Missouri. American Academy of Pediatrics, Elk Grove Village, Illinois. Immunization Svcs Div, National Immunization Program, CDC.

References: 10 available